Challenges faced by skilled birth attendants in providing antenatal and intrapartum care in selected rural areas of Myanmar

WHO South-East Asia Journal of Public Health 2012;1(4):467-476 467 Policy and practice Challenges faced by skilled birth attendants in providing antenatal and intrapartum care in selected rural areas of Myanmar Kyaw Ooa, Le Le Wina, Saw Sawa, Myo Myo Mona, Yin Thet Nu Ooa, Thae Maung Maunga, Su Latt Tun Myinta, Theingi Myintb Background: In Myanmar a large proportion of antenatal and intrapartum care in rural areas is provided by skilled birth attendants (SBAs), this study assessed the coverage by these health workers of all births, their adherence to service guidelines, and community opinion on the antenatal and delivery care they give in two rural health centres in Pathein Township, Ayeyarwaddy Region to identify the challenges and improve antenatal and intrapartum service delivery provided by the SBAs. Method: A structured questionnaire was used to interview 304 women who had infants under one year of age, and in-depth interviews were held with 12 SBAs and 10 community members. Results: Of the 304 pregnancies, 93% had received antenatal care (ANC); 97% of these were covered by SBAs at an average 15 weeks’ gestation. The average frequency of ANC visits was 9. Rates of home and hospital deliveries were 84.5% and 13.8% respectively. Among home deliveries, use rate of SBA was 51.4%, while for postnatal care, 31.3% was given by unskilled providers (traditional birth attendants (TBAs) 17.5%, auxiliary midwives (AMWs),13.8%). Multivariate analysis showed that interviewees aged 30 years and below (OR=0.468, P=0.046), with an education at primary level and below that of husband (OR=0.391, P=0.007) or not residing in the village of the rural/station health centre (OR=0.457, P=0.011) were significantly less likely to use SBAs. The categories of supervision, referral, and health education activities of SBAs were not in line with service guidelines. The main reasons were lack of access and community acceptance of TBAs. Conclusion: Heavy workload, geographical location, transportation and financial concerns were major challenges for SBAs, along with community compliance and mutual coordination. Good communication and service management skills were important to overcome these challenges. Key words: antenatal care, maternal and child health, Myanmar, skilled birth attendant (SBA), home delivery. aDepartment of Medical Research (Lower Myanmar), Ministry of Health, Yangon, Myanmar. bDepartment of Health, Ministry of Health, Yangon, Myanmar. Correspondence to Yin Thet Nu Oo (e-mail: yinthet@gmail.com) Introduction In Myanmar, maternal and child health, including newborn care, has been prioritized with the aim of reducing morbidity and mortality of mothers and children. Safe motherhood initiatives have expanded into a national movement focusing on the rural WHO South-East Asia Journal of Public Health 2012;1(4):467-476468 Challenges faced by skilled birth attendants in providing antenatal and intrapartum care in selected rural areas of Myanmar Kyaw Oo et al. population. Approximately 1.3 million women give birth each year in Myanmar. The chance that a woman will die from pregnancy-related causes is 1 in 33 and skilled birth attendants (SBA) are present at only 40% of deliveries and just over 20% of institutional deliveries.1 Although improvements in the health status of mothers and children have been made, much more needs to be done to sustain the gains.2 Even though mothers tend to deliver more children in rural than in urban areas, 80% of deliveries are at home,3 of which the majority are by unskilled birth attendants. High home delivery rates and low use of skilled providers are addressed in the country’s strategic plans, which comprise improved skills and capacity of providers, family and community practice, and service delivery systems. Information on challenges in improving these three major pillars would support Myanmar’s strategy for more effective implementation of a reduction in the maternal mortality ratio (MMR). Thus, this study tried to identify the challenges and ways to improve antenatal and intrapartum service delivery provided by skilled birth attendants in rural area. Methodology The study was conducted at Pathein Township in Ayeyarwaddy Region, which was selected because of its low township coverage by SBAs compared with the national average (51% in Pathein, 63.6% national coverage).4 Two rural health centres – Thalakkhwar Station Health Unit and Kyetpaung Rural Health Centre– were be selected for their relatively high and low SBA rate respectively. A sample of 300 mothers who had given birth in the previous 12 months were interviewed with a structured questionnaire exploring antenatal and delivery care-seeking practice. User opinions and community perspectives on services provided were explored by key informant interviews with 10 community members including TBAs and local community leaders. Providers’ adherence to service delivery guidelines was assessed by reviewing records and carrying out in-depth interviews with 12 basic health staff (BHS) in the selected health centres. Quantitative data were entered by EpiDatatm and analysed by SPSS version 16. Qualitative data were processed in content analysis to address compliance, satisfaction and choice of services. Matrix analysis was also made to identify existing challenges in skilled attendance. Findings Profile of study area Pathein Township had a population of 380 460 and an urban–rural ratio of 1.01:1. The number of women of reproductive age was 87 505. Its nine health centres count 126 BHS spread over six rural health centres (RHC) and three station hospitals. There were 85 functioning AMWs and 66 trained TBAs, and in 2009, ANC coverage was 59.6%, SBA rate was 51% and referral rate was 5.6%. Delivery rate attended by AMWs was 12.6% with a 9.7% referral rate, while deliveries attended by trained TBAs were 7.3%, with a 7.4% referral rate. Rates for maternal mortality, infant mortality and neonatal mortality were 2.4, 15.1 and 4.7 per 1000 live births respectively. The abortion rate was 3.04.5 Past obstetric history and care-seeking practice A total of 304 women were interviewed. Their age ranged from 17 to 45 years with a mean (SD) of 29.4 +6.5 years. The average family size was five, two of whom were earning members; 30% of women and 60% of husbands were daily wagers and 42% of women were dependent. About 90% of women WHO South-East Asia Journal of Public Health 2012;1(4):467-476 469 Challenges faced by skilled birth attendants in providing antenatal and intrapartum care in selected rural areas of Myanmar Kyaw Oo et al. and their husbands were of low to middle-level education. The ethic group Bamar accounted for 65% of the population, the remaining being Kayin. The ratio of Buddhist to Christian was 2:1. Half of housing is built from wood and bamboo, and 35% are made from bamboo and thatch. The route to the nearest health centre for 60% of subjects was on foot, and for 24% by bicycle. The median duration to reach the health centre was 20 minutes. Some 50% of women needed 10–30 minutes to reach the nearest health centre. Travel expenses varied from an average 1000 kyats to a maximum of 4000 kyats (equivalent to 5 US$). The median number of children of the study group was 2. Of a total 776 previous pregnancies, 84.4% had registered at the antenatal clinic. Stillbirth and abortion rates of these pregnancies were 0.7% and 1.8% respectively. Antenatal booking rates tapered with later order of parity (Figure 1). The location of the antenatal booking for first parity was mostly at health centres or general practitioner clinics. Recent antenatal, intranatal and postnatal care practice Antenatal booking rates for last pregnancies was 93%, 97% of which occurred with skilled health personnel. The average gestational period of antenatal bookings was 15 weeks. The average frequency of ANC visits was 9 (median=6). Half of women made antenatal bookings between 12–20 weeks of gestation and visited 4–10 times for ANC. One third of pregnancies experienced oedema and 18% noticed high blood pressure. The last pregnancies were delivered on average in the 37th gestational week. Half of Figure 1: Percentage of antenatal booking by parities WHO South-East Asia Journal of Public Health 2012;1(4):467-476470 Challenges faced by skilled birth attendants in providing antenatal and intrapartum care in selected rural areas of Myanmar Kyaw Oo et al. women delivered between 36 and 38 weeks’ gestation. The rate of SBAs used was 59.1%. Delivery rates at home and hospital were 84.5% and 13.8% respectively. Among home deliveries, use rate of SBA was 51.4%. During delivery, 2.6% of cases changed birth place, mainly to hospitals to receive the services of skilled providers. The referrals were mainly made by midwives, TBAs, AMWs and medical doctors (Figure 2). The major problem faced after delivery was haemorrhage. SBA rates at the start of labour, during delivery and after delivery were 52%, 53% and 52.9%, indicating no significant difference in birth attendance per phase of labour. Rates of skilled attendance at home delivery for all pregnancies was high – 91% at the start of labour – showing that most births were planned at home. However, given that 88% of deliveries actually occurred at home, 3% of deliveries had changed location between first labour pains and birth. Nearly one-third (31.3%) of postnatal care was provided by unskilled workers (TBA=17.5% and AMW=13.8%). Postnatal problems occurred among 5.6% of cases after their last deliveries. Most problems were minor medical illnesses that were not referred. Factors associated with the use of skilled birth attendants The use of SBA, operationally defined as “use at delivery”, was grouped into three categories: never use, sometimes use and always use. Bivariate analysis showed that the following indicators were associated with higher use of SBAs: better access to a health Figure 2: Proportion of basic health services that need support to meet the set guidelines WHO South-East Asia Journal of Public Health 2012;1(4):467-476 471 Challenges faced by skilled birth attendants in providing antenatal and intrapartum care in selected rural areas of Myanmar Kyaw Oo et al. centre, i.e. residing in RHC main village (46% vs 35%, P=0.005), higher education level of women (58% vs 36%, P=0.002) and husbands (57% vs 34%, P<0.001), good housing status (P=0.04), younger age of woman (44% vs 37%, P=0.001) and husband (48% vs 35%, P=0.003) (Table 1). Multivariate analysis (multinomial logistic regression) showed that younger women, i.e. 30 years and below (OR=0.468, P=0.046), low level of husband’s education, i.e. primary and below (OR=0.391, P=0.007), not residing near RHC (OR=0.457, P=0.011) were significant factors for lower use of SBA (Table 2). Adherence to service delivery guidelines The 12 BHS interviewed had an average total service of 15 years (range 3.5–29 year). Nine BHS were graduates and the remaining three had passed high school. A variety of registries and report books were reviewed during the interview. Activities that deviated most frequently from the guideline instruction laid down by the Department of Health6 were related to providing antenatal care, providing delivery care, and service management. Others were supervisory, referral and health education activities (Figure 2). Regarding delivery care, most deviations were due to difficult access and community acceptance and use of TBA services, as illustrated below. We could not go to them because they are staying in the middle of a paddy field alone and there was no road. Some area in my coverage is far from me and nearer to another midwife. She wishes to get service of that midwife. TBAs are over there since long, long ago. They can give service for uncomplicated cases…Accessibility is their priority. Deviations from antenatal care guidelines were the inability to cover 100% of cases, non-provision of some antenatal examinations (especially height measurement, urine albumin test), and some inadequate antenatal visits, exemplified as follows. Many women did not come regularly and for those women, we cannot give antenatal care service for full frequency. …we have no time to check urine of all women. Thus we check only those who have high blood pressure… Height measuring also could not be done for all women. Only if we suspect she is short we measure and record. …sometimes we have to skip some procedure stated in the guideline …to get satisfaction of clients, to save their time, and to get their compliance… Among the three types of BHS, most deviations were found in the provision of services by lady health visitors (LHV), and the least in the activities of midwives (Figure 6). Most frequent reasons were deficient facilities/ equipment/materials, lack of accessibility and low compliance of the client. The next most frequent reasons were time constraints, weak supervision system and community compliance or use of TBA services (Figure 3). Regarding ANC service provision, improving management skills (including planning, prioritizing and adapting to the situation) is the first priority for BHS in order to be able to face and overcome challenges. Secondly, improved skills in cooperation mechanisms with TBAs, AMWs and local authorities were considered important (Figure 4). We could not avoid TBA because they are more accessible and have better relationship WHO South-East Asia Journal of Public Health 2012;1(4):467-476472 Challenges faced by skilled birth attendants in providing antenatal and intrapartum care in selected rural areas of Myanmar Kyaw Oo et al. Table 1: Factors associated with use of SBA in previous and last pregnancies (bivariate analysis) Factor Use of skilled birth attendant Total χ2 (df) P Never Sometimes Always Residing at or near to HC 10.574 (2) 0.005 Residing at subcentre Freq 60 28 48 136 % 44.1 20.6 35.3 100 Residing at HC Freq 44 47 77 168 % 26.2 28.0 45.8 100 Age (years) 13.604 (2) 0.001 <= 30 Freq 69 30 77 176 % 39.2 17.0 43.8 100 31+ Freq 35 45 48 128 % 27.3 35.2 37.5 100 Age (years) husband 11.363 (2) 0.003 <= 30 Freq 54 25 72 151 % 35.8 16.6 47.7 100 31+ Freq 50 50 53 153 % 32.7 32.7 34.6 100 Education level 12.867 (2) 0.002 Illit+Pri Freq 87 58 80 225 % 38.7 25.8 35.6 100 Middle or above Freq 16 17 45 78 % 20.5 21.8 57.7 100 Husband's education level 17.934 (2) 0.000 Illit+Pri Freq 84 50 68 202 % 41.6 24.8 33.7 100 Middle or above Freq 20 23 57 100 % 20.0 23.0 57.0 100 Housing status 12.151 (4) 0.016 Bamboo Freq 49 49 62 160 % 30.6 30.6 38.8 100 Wooden or Brick Freq 8 5 20 33 % 24.2 15.2 60.6 100 Other Freq 46 21 40 107 % 43 19.6 37.4 100 Freq=frequency; HC= health centre; Illit+Pri= grouping from illiterate to primary education. Other non-significant factors not described in the table are health centre (P=0.996); occupation (P=0.657); race (P=0.708); religion (P=0.537); family monthly income (P=0.74); husband’s occupation (P=0.21) WHO South-East Asia Journal of Public Health 2012;1(4):467-476 473 Challenges faced by skilled birth attendants in providing antenatal and intrapartum care in selected rural areas of Myanmar Kyaw Oo et al. Table 2: Multivariate analysis of significant factors for use of SBA (multinomial logistic regression) Use of SBA (Ref: Never use) P value OR 95% CI of OR Lower Upper Always used Age (<=30 vs >30) 0.046 0.5 0.2 1.0 Age of husband (<=30 vs >30) 0.104 1.8 0.9 3.8 Education (<=primary vs >primary) 0.163 0.6 0.3 1.2 Education of husband (<=primary vs >primary) 0.006 0.4 0.2 0.8 Housing (bamboo vs wood/brick) 0.718 0.8 0.3 2.2 Housing (other vs wood/brick) 0.284 0.6 0.2 1.6 Health Centre (RHC vs SHU) 0.585 1.2 0.7 2.1 Residence (sub-centre vs main) 0.011 0.5 0.2 0.8 OR, odds ratio; RHC, rural health centre; SHU, station health unit; Results for “sometimes used” category were omitted since the factors for use of SBA were similar to the results for “always used” category. Figure 3:Reasons for deviation of service provision from the guideline WHO South-East Asia Journal of Public Health 2012;1(4):467-476474 Challenges faced by skilled birth attendants in providing antenatal and intrapartum care in selected rural areas of Myanmar Kyaw Oo et al. with local people. In hard to reach areas, we have to cooperate with them. If we cooperate, risk cases will be more access to us and be referred. Community opinion towards skilled providers Community informants felt that midwives could cover about two thirds of all deliveries and almost all antenatal activities and immunization, including tetanus toxoid vaccination. The remaining deliveries were carried out by AMWs and sometimes, especially in hard-to-reach areas, by TBAs. Community informants noted that midwives would try to assume all deliveries in their responsible area but are unable to cover everything, which the community appreciated. We see midwives frequently in our village ... especially for vaccination. People know that midwives are more skilful but could not always be available …[they] stay far away and thus more costly. Key informants estimated home delivery to be about 90%, with hospital delivery only in cases of emergency. All respondents agreed that the main challenge for midwives was overburden of their workload. A midwife cannot rapidly reach all patients if she is responsible for 7–10 villages. In addition, midwives sometimes need to go to town for a meeting or training. Client access to health providers was low. Half of villages under SBA coverage were too far away from the sub-centre to reach in time. Emergency situations made clients more inclined to use a health provider who was nearer and could respond rapidly whether or not s/he was skillful enough. Pregnant women who were residing in less accessible areas could not use the skilled provider due to geographical barriers, or transportation difficulties, occurring seasonally in the outreach areas covered by midwives. Seasonal fluctuations affect access to roads and diurnal variation of waterways in the delta area. Thus, in an emergency, the inability to travel means that clients cannot use a skilled provider even if they wanted to. A further challenge for skilled providers was poor cooperation of local people and authorities to encourage clients to use skilled personnel and to comply with referrals. They stated that community support was low, especially in delivery care. The last challenge, essential for referral, was coordination between skilled providers of health centres from different levels. Poor coordination by the providers and financial concerns of the health centre makes the provider reluctant to refer, and leads to client non-compliance. Usually, local voluntary providers cooperate with midwife ANC and immunization services by making arrangements for the location, transportation and organization of clients. In some instances, cooperation between AMWs, trained TBAs and midwives was supportive for midwives to develop a close relationship with local authorities and to gain client compliance. Cooperation was indirectly supportive for midwives’ intrapartum care services in being informed of problem cases, compliance with referral, transportation assistance and the resolution of financial issues. Discussion Unpredictable obstetric complications are developing in 15–20% of pregnancies. A major proportion of deaths resulting from these complications occur either at home or in transit.4 Increased access to, and quality and quantity of health facilities in the country WHO South-East Asia Journal of Public Health 2012;1(4):467-476 475 Challenges faced by skilled birth attendants in providing antenatal and intrapartum care in selected rural areas of Myanmar Kyaw Oo et al. could reduce maternal mortality dramatically, according to SriLanka experiences.7,8 Though safe motherhood is a high priority programme, 90% of deliveries still occur at home and 50% are attended by TBAs.2 Specific challenges remain for Myanmar to reduce its MMR. Low education and economic status, and lack of access influence the client’s decision to use skilled providers in pregnancy care. Providers also highlighted accessibility as a challenging factor to increase SBA use. This challenge was reiterated by community key informants for skilled providers to be able to provide full coverage. Accessibility means all geographical, managerial and financial aspects both by clients and providers. For some midwives, their area of responsibility and the size of the population were too large for them to meet their targets for full coverage of ANC and SBA. Geographical barriers can prevent both clients and providers from meeting their needs. Deviations of skilled providers’ services from the guideline were mainly caused by having responsibility for too wide area and too large population size, little time and lack of facilities. Service manuals were not found in all BHS hands. Many descriptions in the manuals confuse them. The role of lady health visitors in rural areas should be emphasized with practical service-provision and supervisory activities over the midwives, especially for coordination between BHS and the community. Furthermore, all perspectives considered that clients’ habitual use of unskilled providers was due to a low level of education and because unskilled providers were more accessible than skilled providers. Conclusion Skilled attendance for all births is the only way to ensure emergency obstetric care for all pregnancies with complications. The percentage of births attended by skilled health workers is considered to be the most appropriate process indicator. Current estimates indicate that globally, only 56% of births are assisted by a skilled person.9 Although communities suggested more skilled staff in their areas, manpower and resources are scarce. The country’s strategic plans should therefore focus on improving the capacity of current health providers, especially in management and communication; and improving family and community practice through close coordination with community authorities and health volunteers. Regarding cooperation, the delegation of some services, accompanied by close and supportive supervision, good communication and motivation with positive attitudes, would be effective. This study highlights the major challenges and suggests priorities and ways to overcome them. The objective would be to implement a more effective national strategic plan, with the ultimate goal of reducing MMR. Acknowledgements This study was conducted with funding from WHO. The Directors Generals of the Department of Medical Research (Lower Myanmar) and the Department of Health gave their kind permission and supervision for the field work. The health authorities of Ayeyarwaddy Regional Health Division and Pathein Township Health Department are specially thanked for their hospitality and kind assistance in field data collection. References Myanmar, Ministry of Health. Health services in 1. Myanmar. 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